surfeit

Finally, I got enough vascular surgery in one day to satisfy my ambitions.

One of the vascular attendings is renowned amond the residents for his painstaking approached. He stops to look at the vein every few minutes while harvesting it, ties off things that may or may not be branches (as opposed to just tying off things which definitely seem to be branches; his approach takes more time), thinks for a long time about the path of his graft, and stops to assess the anastomosis several times while sewing it to make sure it isn’t kinking. He has been known to finish a 3 or 4 hour case, look at the anastomosis, and then take the whole thing down and start over because of a miniscule kink. In other words, he’s a perfectionist among vascular surgeons, who are perfectionists to start with. Also, he has a penchant for trying things that everyone else has given up on: dialysis access on a patient whose arms are covered with scars from failed fistulas and grafts; lower extremity bypasses on patients with 2mm veins for conduit (right on the margin of being too small to try), or whose only target vessel is a dorsalis pedis (so far down the leg that the vessel is tiny, and the utility is unpredictable; but they’ll lose the leg for sure if you don’t try). Thus, many people are happy not to get into the OR with him, knowing they’ll spend the whole day getting frustrated, and end up stuck late into the night, by the time he finishes his long OR list of difficult cases.

Which is a brilliant opportunity for the junior resident. The chief has gone off to do a glamorous great vessel reconstructive bypass (eg carotid-subclavian) with the attending who believes that speed is an essential factor for success in vacular surgery, and I’m left to do the entire day’s worth of cases with this first attending. It was great. Sure, he stopped every few minutes to think about the vein we were freeing up, and constantly expressed concern that I was about to cut a blood vessel (which was only what I was thinking to myself the whole time), but he let me do essentially all the dissection, and let me sew the entire anastomosis, no matter how slowly I went, or how maddeningly awkward I was with the 7-0 suture and Rankin needledrivers (7-0 suture is nearly invisible to the naked eye, and the needledrivers used for it are very delicate, and designed to let go of the needle so you don’t tear the vessel with it, making it difficult to hold onto the needle enough to make it go where you want before it lets go).

As we dissected out the veins to use for an AV fistula (for dialysis), or even worse, the artery to attach to, I kept misjudging the tissue, and cutting across a tiny branch before tying it off. This isn’t really the end of the world, but it gets blood all over the field, making it even more difficult to tell tissues apart, and it necessitates several minutes spent hunting down the two ends of the vessel and tying them off. Every time we had to stop and clean up, I was sure he would take over. But every time, he handed me back and the scissors, and let me keep going (which was almost more difficult; after a couple such failures, I would almost rather have had him take over and do it neatly, rather than force me to keep struggling; but it was much better learning). I certainly felt better when, in a few heavily scarred or complex areas, he did take over, and also got into bleeding that we had to hunt down.

At any rate, three such cases took us till 5pm. There was one “quick” debridement case on after that, but we were late enough to get caught in the switch of OR staff: the day people, who hurry a little bit in order to get done by the end of their shift so they can leave on time, were replaced by the night duty folks, who took the approach that they were going to be here till midnight no matter what happened, so if it took an hour to get our last case started, it didn’t really matter to them. I try to help and hurry things up, but there’s a limit to the number of times you can say “maybe we’re ready now?” before people get tired of you. Then, it turned out that the debridement was necessary because there was several inches of infected graft needing to be taken out, and the case lasted a few hours, and ended up requiring dissection into all kinds of places other than the one originally advertised. I was still pleased with myself. The attending let me do most of the dissection, even in an infected, scarred field where we were very unsure of the anatomy (as opposed to a untouched field, where you expect the arteries and veins to be in known locations).

So what, I didn’t get home till 9pm. That’s par for the course with this attending, and I had gotten to operate all day straight. The loupes were even starting to feel natural by the end of the day. Too bad that this attending books such full days only occasionally.